Provider Demographics
NPI:1407487341
Name:MARTIN, CHRISTY SUE
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:SUE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 BACKUS RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:NY
Mailing Address - Zip Code:14047-9511
Mailing Address - Country:US
Mailing Address - Phone:716-982-3479
Mailing Address - Fax:
Practice Address - Street 1:4650 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-1939
Practice Address - Country:US
Practice Address - Phone:716-648-2450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035219261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy